Program Director Information
Complete the table below with the program director’s information.
Name:
Title:
Credentials (MD, MPH, etc.):
Address:
City
State:
Telephone:
Zip code:
FAX:
Email:
Date the program director was first appointed:
Primary specialty board certification:
Most recent certification/recertification date:
Secondary specialty board certification:
Most recent certification/recertification date:
Is the program director ABMS or RCPSC (i.e., ABPN, ABIM) certified?
YES
NO
Is the program director UCNS certified in Neurocritical Care?
YES
NO
YES
NO
YES
NO
YES
NO
Number of years spent teaching in GME in this subspecialty:
Is the program director a full-time staff member of the sponsoring or primary institution?
Does the program director hold a current license to practice medicine in the state of the
sponsoring or primary institution?
Is the program director based at primary teaching institution?
Percentage of hours per week the program director spends in:
Clinical (Time
spent in patient
care):
Administration (Time
spent in program
administrative duties):
Is the program director also the department chair?
Research (Time
spent completing
research activities):
YES
Education (Time spent
instructing fellows and
preparing instruction
materials):
NO
If no, chair name and credentials:
Template forms must be used / Only provide requested information
UCNS Program Change Program Director Information Table
Page 1 of 1
2014